The City Losing Its Children to H.I.V.

A pediatric outbreak in a remote Pakistan city shows the urgency of global health after Covid.

The journalist Gulbahar Shaikh helped expose the outbreak in Ratodero. His 1-year-old daughter Rida tested positive for H.I.V. shortly after his broadcast.Credit…Sarah Caron for The New York Times

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By Helen Ouyang

Photographs by Sarah Caron

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One day in February 2019, Nazeer Shah carried his 1-year-old daughter, Eman, into a medical clinic. The doctor there, Imran Arbani, was immediately alarmed: The girl was limp and lethargic, her head flopped over on her father’s shoulder. Her breathing was shallow and fast. She was asleep, hard to rouse, except when she woke to cough. She drooled from her mouth. Her tongue was covered with a thick white coating, which Arbani recognized as thrush, a condition that usually indicates a weakened immune system. At around 11 pounds, she was frighteningly underweight.

Shah told the doctor that Eman was born healthy and was well until three months earlier, when she began having diarrhea daily. Her weight dropped precipitously; she spiked fevers regularly. Every day she seemed worse than the day before. Shah handed the doctor a green plastic bag filled with assorted syrups and pills — more than a dozen different medications. These were all the things she had tried, he explained. Nothing helped. He had taken her to several doctors here in Ratodero, an impoverished city in southeastern Pakistan, and to specialists in Larkana, a city roughly 20 miles to the south. He couldn’t get any clear answers.

Shah lives close to Arbani’s clinic but was initially hesitant to take Eman to him because his specialty was urology. Arbani, however, is used to practicing family medicine as well. “A doctor is a doctor,” he says. “The people do not treat doctors who are specialists as specialists. I deal with a lot of general problems too.” Arbani, who has thick, expressive eyebrows and speaks in quick, forceful clips, told Shah that he wanted to test the girl for the human immunodeficiency virus.

This article was supported by the Pulitzer Center.

“Doctor, are you joking, saying she might have H.I.V.?” Shah replied. “How is it possible?” But it was seemingly the only test that had not been done yet, so Shah drove Eman on his motorbike to a local laboratory, where a health care worker pricked her finger for a drop of blood. They waited outside for half an hour, until Shah was given a slip of paper. “Weak positive,” it read.

“I was still confident at that point,” Shah told me. “It could be negative.” He took the results to Arbani, who suggested that Shah send another test to a satellite lab in Larkana run by Aga Khan University Hospital in Karachi, one of the country’s premier academic medical centers. Afterward, Shah returned to Arbani’s clinic so that together they could look at the results, which were available online. When they saw the word “reactive,” Shah began to weep.

Arbani counseled him on the next steps and advised that Eman go to Karachi, more than 300 miles away, because the closest H.I.V. treatment facility, in Larkana, was set up to treat adults. Shah, who had a stable bank job at the time, was able to scrounge up the 2,400 rupees, or about $15, for his family’s bus fare. (The average household income in Pakistan is around $260 a month; most in Ratodero survive on far less.) He spoke to a close friend and told him about his daughter’s condition. The response shocked him.

“My kid already has H.I.V.,” Shah’s friend said. Eman, it turned out, was not the first young child infected with the virus in Ratodero, where more than 300,000 people live. Shah’s friend’s son received the same diagnosis two years before. In each case, the parents tested negative for H.I.V.

In 2020, about 2.8 million people worldwide under the age of 20 were living with H.I.V.; over half of them were younger than 10, according to UNAIDS, the United Nations H.I.V. program. In a vast majority of these cases, the infection was acquired through vertical transmission, meaning an H.I.V.-positive mother passed the virus to her child during pregnancy or delivery or while breastfeeding. It was unusual that these two children in Ratodero had H.I.V. when their parents did not. Nor did either child have a chronic disease that would require rounds of blood transfusions or routine kidney dialysis, which could possibly expose them to blood-borne illnesses. The two previous major outbreaks in the area — one among drug users who used needles and another among patients at a contaminated dialysis center — involved higher-risk populations.

After Eman’s diagnosis, Arbani began testing many more of the sick children he saw for H.I.V. Within a matter of months, he had identified 14 pediatric patients with H.I.V. All of them were younger than 10.

The big three infectious diseases that plague the world — H.I.V., tuberculosis and malaria — cause more than 2.3 million deaths a year, disproportionately in poorer countries. Until the coronavirus pandemic, though, the overall trend with these diseases was a cause for optimism. Two-thirds of the world’s 38 million H.I.V. patients are now getting treatment, and their expected life spans have been lengthening significantly in recent years, as doctors have increasingly figured out how to forestall acquired immunodeficiency syndrome, or late-stage H.I.V. At the same time, infection rates have been in decline, thanks to advocacy, well-directed funding and smart public-health efforts: New H.I.V. infections have been reduced by nearly a quarter since 2010.

Remarkable advances have been made against malaria too over the last two decades. Deaths caused by the disease have dropped by 44 percent. In 2019, the first malaria vaccine was distributed in sub-Saharan Africa. This is also the region of the world where the largest gains have been made against H.I.V. And while the global campaign against tuberculosis has had less success — in large part because of the emergence of multiple-drug-resistant strains of the bacterium responsible for the disease — progress has nevertheless been steady, with a drop in deaths of nearly 15 percent over the last five years.

Now another virus has been threatening to undo this progress. Over the course of barely a year, the coronavirus has infected more than 120 million people worldwide, directly claiming the lives of more than 2.7 million. Coronavirus infections have disrupted medical services, scrambled drug-supply chains and necessitated the redeployment of public-health staff. According to the Global Fund, an international organization that finances health initiatives, about 75 percent of H.I.V. programs have already been moderately or severely disrupted.

This has dire implications: UNAIDS estimates that even a six-month interruption of antiretroviral therapy for 20 percent of people would result in more than 110,000 additional deaths. In a September study in The Lancet Global Health, researchers modeled the impact of Covid-19 on H.I.V., tuberculosis and malaria. Over the next five years, in low- and middle-income countries where these diseases are highly prevalent, deaths could increase up to 10 percent for H.I.V., 20 percent for tuberculosis and 36 percent for malaria.

For these reasons, Mishal Khan, a policy analyst at the London School of Hygiene and Tropical Medicine who studies Pakistan’s health system, says she doesn’t want “everything to be about Covid, because it’s not like the other issues will go away.” They’ll just “get neglected,” she adds, because even infectious diseases that have been “taking lives for decades” haven’t been tracked as closely as Covid-19. The diversion of resources from H.I.V. and other health conditions to the pandemic inevitably affects the most vulnerable. As António Guterres, the U.N. secretary general, warns in a UNAIDS Global Report, H.I.V. and Covid-19 have each exposed “our world’s fragilities — including persistent economic and social inequalities and woefully inadequate investments in public health.”

In Pakistan, H.I.V. numbers have long been trending in the wrong direction. The most recent data indicate that only 21 percent of those infected with H.I.V. in Pakistan are aware of their status. According to UNAIDS, there are an estimated 190,000 H.I.V.-positive people in the country, and only 12 percent of them receive treatment. As a result, there has been a 385 percent increase in H.I.V.-related deaths in Pakistan since 2010. Sub-Saharan Africa, in contrast, has had a 45 percent decline over that same period. Pakistan has one of the fastest-rising rates of infection in Asia and the Pacific.

Why has there been a resurgence of H.I.V. in Pakistan even as it has declined elsewhere? Much of the reason is money — specifically, the lack of consistent and equitable government spending on health. According to the World Bank, just over 3 percent of the country’s gross domestic product goes toward health, one of the lowest such allocations in the world; its neighbor Afghanistan devotes nearly 10 percent. Per person, less than $45 is spent on health care annually in Pakistan, which relies heavily on foreign aid; in the United States, which has the highest per capita health care expenditures in the world, the amount is around $10,600. Life expectancy for the average Pakistani is 67 years, more than a decade shorter than it is for Americans. Pakistan, one of three countries that has not eradicated polio, also currently bears some of the heaviest burden from tuberculosis, at least in part because being H.I.V.-positive increases the risk, by roughly 20-fold, of developing the disease.

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